Ortho part 2 Flashcards
Scaphoid fracture
Point of maximal tenderness lies in anatomic snuffbox
Lunate fracture
Palpable on dorsal radius
Axial loading of the third metacarpal may increase pain
Colles fracture
Dinner fork deformity
Smith fracture
Volar displacement of the wrist relative to the forearm
Workup of wrist fracture
AP, lateral, and oblique XRs
Tx of wrist fx
Reduction and immobilization
Sedation/anesthesia beforehand
Conscious sedation is becoming the method of choice
Colles, Smith, volar and dorsal dislocations, triquetrium: sugar-tong splint
Scaphoid: thumb-spica splint
Lunate: short-arm spica cast or splint with thumb immobilization
Pisiform: volar splint
Hamate: short-arm cast with 4th and 5th MCP joints heald in flexion
Hx details to get with hand fx: general
Hand dominance of the pt
Hand that is injured
Occupation and hobbies requiring dexterity
Hx details to get with hand fx: MOI
Did injury occur in a clean or dirty environment?
Were crush injuries sustained?
What was the position of the hand at the time of injury?
Was injury the result of high-pressure grease, water, air, or paint injection?
Did a thermal, electric, or chemical injury occur?
Was pt wearing any type of jewelry on fingers?
If so, has it been removed?
Hx details to get with hand fx: assault
Was hand open or fist clenched?
Are lacs present?
Did the pt’s fist contact mouth or teeth?
Sensory nerves of hand
Ulnar nerve supplies the fifth finger and the medial aspect of the fourth finger
The median nerve supplies the volar aspect of the 1st through 3rd fingers as well as the lateral aspect of the volar surface of the 4th finger
The radial nerve supplies the dorsal surface of the entire hand except for the 5th finger
Motor nerve components of the hand
The radial nerve extends the wrist and the fingers
The ulnar nerve allows adduction of the 4th and 5th fingers and adduction of the thumb
The median nerve adducts the 2nd and 3rd fingers and allows opposition of the thumb to the 5th finger
Hand fx workup
AP, lateral, and oblique XRs
Hand fx tx- general
Most simple hand fxs may be treated with padded aluminum splints or buddy taping
All pts should be referred to hand surgeon except distal phalanx fxs
Treat any subungual hematoma with trephination or nail removal. Tx is controversial
Abx required with nail removal
Hand fx tx- mallet finger, transverse fx of distal phalanx, middle and proximal phalangeal fxs
Mallet finger- exploration and open fixation vs splinting alone
Transverse fracture of distal phalanx- splint
Middle and proximal phalangeal fractures- surgery
Hand fx tx-middle phalanx, transverse fx of proximal phalanx, oblique and spiral fxs
Middle phalanx- splint, buddy tape if phalanx is stable
Transverse fx of proximal phalanx- Splint, and frequently, open reduction
Oblique and spiral fxs- Splint with either ulner or radial gutter splint
Hand fx tx- condylar, metacarpal head, and metacarpal neck fxs
Condylar fx- open fixation
Metacarpal head fx- Splinting with immediate orthopedic referral
Metacarpal neck fx- closed reduction, gutter splint, and prompt orthopedic referral
Hand fx tx- metacarpal shaft, metacarpal base, Bennet, and Rolando fxs
Metacarpal shaft- Splint for 4-6 wks, multiple fx and those with shortening, angulation, or rotation usually require fixation
Metacarpal base- Gutter with immediate hand surgeon referral
Bennett- oblique, intraarticular fx at the volar base of the ulnar aspect of the first metacarpal. Thumb spica splint and ortho referral
Rolando- a large dorsal fragment creates a T or Y shaped fx at the base of the first metacarpal
Pathophys/etiology of hip dislocation
Posterior dislocation is MCC with a large force required to dislocate the joint
MVCs are common, but falls from height are also a significant cause
With MVCs, the injury can occur with the knees striking the dashboard
H/o hip dislocation
Keep a high index of suspicion with major trauma, such as an MVC, significant fall, or an athletic injury
Severe pain, may go to lower extremities, back, or pelvic areas
Difficulty moving the lower extremity on the affected side and may complain of numbness or paresthesias
PE of hip dislocation
Assess ABCs Posterior: hip is flexed, internally rotated, and adducted Anterior: Hip is minimally flexed, externally rotated, and markedly abducted In anterior, femoral head can occasionally be palpated Severely limited ROM Signs of sciatic nerve injury: Loss of sensation in posterior leg and foot Loss of dorsiflexion or plantar flexion Loss of DTRs at the ankle Signs of femoral nerve injury: Loss of sensation over the thigh Weakness of the quadriceps Loss of DTRs at knee Signs of vascular injury: Hematoma Loss of pulses Pallor
Workup of hip dislocation
Type and crossmatch
AP pelvis radiograph
CT pelvis
Reduction
Tx of hip dislocation
Stabilize life-threatening injuries Perform proper neurovascular exam Procedural sedation Reduction Fracture-dislocations should be referred to ortho Confirm reduction with radiograph
H/o hip fractures
In elderly pts, hip fx usually occurs from a simple fall
Sometimes, occurs spontaneously
Complaint of pain and inability to move the hip
Stress fxs in young athletes and nondisplaced fxs, pain in hip or knee and may be ambulatory
PE of hip fractures
Make sure pt is not in shock
Femoral head fx: posterior dislocation is most common, with adduction and internal rotation
Femoral neck fx: With partial and completely displaced fxs, severe pain and lies with the extremity slightly shortened, abducted, and externally rotated
Trochanteric fx: Greater trochanter fx, pain, esp with abduction and extension. Lesser trochanter, pain with flexion and internal rotation
Intertrochanteric fx: Extremity appears shortened and significantly externally rotated. Pain, hip edema and ecchymosis, and pain with any movement
Subtrochanteric: Proximal femur usually is held in fexion and external rotation
Common causes of hip fxs
Young: trauma associated with significant force
Osteoporosis is the leading cause
Workup of hip fx
AP and lateral views
If findings are equivocal, consider CT scan
If not found, MRI
Tx of hip fx
Obvious femur fx: immobilize, 2 large-bore IV lines, NPO, perioperative labs
Femoral head: Type 1, ortho consult, if single reduction fails, ORIF
Type 2: ortho consult for admission, arthroplasty
Femoral neck: Type 1, immobilization in selected pts
Types 2, 3, and 4: ORIF or arthoplasty
Trochanteric: Type 1, ortho consult
Type 2: reduction and internal fixation
Intertrochanteric: Traction splint, IVF, ORIF with early ortho consult
Subtrochanteric: IVF, traction splint, ortho surgery consult
Tx of foot fxs: immobilization, toe, first metatarsal
Initial immobilization options: Posterior or stirrup splints Reinforced bulky dressing Rigid, flat-bottom orthopedic shoe Cylindrical cast Toe fx: buddy tape First metatarsal: Immobilization without wt bearing for minimally displaced or nondisplaced. Displaced: ORIF
Tx of foot fxs: internal metatarsal, proximal avulsion, and Jones fxs
Internal metatarsal: Cast or rigid flat-bottom orthopedic shoe. Avoid aggravating activity for 4-6 wks
Proximal avulsion: Compression dressing and wt bearing as tolerated
Jones: Immobilization without wt bearing
Tx of foot fractures: Lisfranc, talar fxs
Lisfranc: immediate ortho consult for reduction and fixation
Talar: neck and body, surgical fixation for displaced and non-wt-bearing short leg cast for 6-10 wks
Lateral process, immobilization without wt bearing
Posterior process, immobilization with either partial or full wt-bearing
Transchondral/osteochondral dome: referral to ortho
Navicular: immobilization or wt bearing as tolerated, unless displaced; ORIF
Tx of calcaneal fxs
Urgent ortho consultation
Etiology of ankle fx
Excessive inversion stress is the MCC
H/o ankle fx
Take hx of how the trauma occurred
Hx of prior trauma
Chronic medical conditions and medications
PE of ankle fx
Gross deformity
Swelling, esp perimalleolar, bony tenderness, discoloration, and ecchymosis
Inability to bear wt on the injured foot
Indications to take radiographs of an ankle in pts with acute ankle pain
Bony tenderness at the distal 6 cm of the posterior edge of the medial malleolus
Bony tenderness at the distal 6 cm of the posterior edge of the lateral malleolus
Inability to bear wt both immediately and in the ED (defined as 4 steps)
Tx of ankle fx
Compromised neurovascular status: reduction ASAP. Maintain with cast, external fixator, or ORIF
Defer reduction of unstable to ortho unless neurovascular compromise
Cover open fxs with wet, sterile dressing
Tetanus when expired
Splinting
What is an unstable ankle fx?
Any fx-dislocation
Any bimalleolar or trimalleolar
Any lateral malleolar fx with significant talar shift
Pathophys of gout
A disorder of metabolism that allows uric acid or urate to accumulate in blood and tissues
When tissues become supersaturated, the urate salt precipitate, forming crystals
Etiology of gout
Genetic causes Comorbid conditions: HTN DM Renal insufficiency Hypertriglyceriemia Hypercholesterolemia Obesity Anemia
Hx of gout
Spontaneous onset of excrutiating pain, edema, and inflammation of the metatarsal-phalangeal joint of the great toe
Other common sites are instep, ankle, wrist, finger joints, and knee
Attacks begin abruptly and typically reach maximum intensity within 8-12 hrs
Can be provoked by consumption of beer or liquor, overconsumption of foods with high purine content, trauma, dehydration, or the use of medications that elevate levels of uric acid
PE of gout
Acute attack most often presents with involvement of a single joint
Involved joints have all the signs of inflammation: swelling, warmth, erythema, and tenderness
Erythema may resemble cellulitis, joint capsule becomes quickly swollen
Pts may be febrile
Tophi present
Workup of gout
Synovial fluid analysis Urinary uric acid Calculate GFR WBC Lipid profile Chronic gout- XR U/s
Tx of gout
Acute attack- NSAIDs, corticosteroids, and ACTH are options
Comorbidities that limit NSAIDs or colchicine- intra-articular steroid injection
